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TR
TENS RX, INC.
15260 HIGHWAY 105 WEST, SUITE 220, MONTGOMERY, TX 77356
(936) 582-2472
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Email
Patient ID
Medical Record Number
Guarantor ID
Guarantor First Name
Guarantor Last Name
First Name
Last Name
Middle
Date of Birth
Patient's date of birth (MM/DD/YYYY).
Phone Number
ZIP Code
Statement Number
Statement Date
Amount Due
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Dynamic Field 3
Dynamic Field 4
ProviderAlias
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